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Exoskeletons for Over-Ground Gait Training in Spinal Cord Injury

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Advanced Technologies for the Rehabilitation of Gait and Balance Disorders

Part of the book series: Biosystems & Biorobotics ((BIOSYSROB,volume 19))

Abstract

Spinal cord injury (SCI) is a traumatic event with a global incidence of 23 cases per million, representing 180,000 cases per annum worldwide. Recovery of locomotion is a main priority for spinal cord-injured patients. In addition to overcoming the obvious mobility and social issues related to the inability to stand or walk, regular ambulation may profoundly combat secondary medical problems associated with lack of weight-bearing activity in SCI patients. Lower limb exoskeletons (EXOs) may be devised as an ambulation device, as a rehabilitation tool or may be aimed at allowing both objectives living. Regarding rehabilitation, it is worth noticing that EXOs also provide a perfect environment for precise assessing of rehabilitation protocols and effects. Different is the case of EXO for mobility, where the old wheelchair is still largely winning the challenge: existing exoskeletons have limitations with respect to affordability, size, weight, speed, and efficiency, which may reduce their functional application. In all functional areas (velocity, safety, portability, acceptance as well as autonomy in the ADL) none of today EXOs can compete with the performances of an average wheelchair. However, EXO usage requires learning, and brain changes associated with tool usage introduce the human in the loop concept, a key aspect of clinical relevance for EXO usage. At present, interesting data on the biological mechanisms and rehabilitation relevance of embodiment are providing hints for guiding rehabilitation. In this chapter, these challenges will be presented from a clinical rehabilitation perspective and expectations and critics discussed.

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References

  1. Aach M, Cruciger O, Sczesny-Kaiser M, et al. Voluntary driven exoskeleton as a new tool for rehabilitation in chronic spinal cord injury: a pilot study. Spine J. 2014;14:2847–53.

    Article  Google Scholar 

  2. Barbeau H, Fung J. The role of rehabilitation in the recovery of walking in the neurological population. Curr Opin Neurol. 2001;14:735–40.

    Article  Google Scholar 

  3. Barbeau H, Ladouceur M, Norman KE, et al. Walking after spinal cord injury: evaluation, treatment and functional recovery. Arch Phys Med Rehabil. 1999;80:225–35.

    Article  Google Scholar 

  4. Barbeau H, McCrea DA, O’Donovan MJ, et al. Tapping into spinal circuits to restore motor function. Brain Res Rev. 1999;30:27–51.

    Article  Google Scholar 

  5. Bastiaanse CM, Duysens J, Dietz V. Modulation of cutaneous reflexes by load receptor input during human walking. Exp Brain Res. 2000;135:189–98.

    Article  Google Scholar 

  6. Belforte G, Gastaldi L, Sorli M. Pneumatic active gait orthosis. Mechatronics. 2001;11:301–23.

    Google Scholar 

  7. Belda-Lois J-M, Mena-del Horno S, Bermejo-Bosch I, et al. Rehabilitation of gait after stroke: a review towards a top-down approach. J Neuroeng Rehabil. 2011;8:66.

    Google Scholar 

  8. Chen G, Chan CK, Guo Z, et al. A review of lower extremity assistive robotic exoskeletons in rehabilitation therapy. Crit Rev Biomed Eng. 2013;41:343–63.

    Article  Google Scholar 

  9. Creasey GH, Ho CH, RJ, et al. Clinical applications of electrical stimulation after spinal cord injury. J Spinal Cord Med. 2004;27:365–75.

    Google Scholar 

  10. Cruciger O, Tegenthoff M, Schwenkreis P, et al. Locomotion training using voluntary driven exoskeleton (HAL) in acute incomplete SCI. Neurology. 2014;83:474.

    Article  Google Scholar 

  11. Curt A, Hedel HV, Klaus D, Dietz V, Group ESS. Recovery from a spinal cord injury: significance of compensation, neural plasticity, and repair. J Neurotrauma. 2008;25:677–85.

    Article  Google Scholar 

  12. del-Ama A, Koutsou A, Moreno J. Review of hybrid exoskeletons to restore gait following spinal cord injury. J Rehabil Res Dev. 2012;49(4):497–514.

    Google Scholar 

  13. Dietz V. Spinal cord pattern generators for locomotion. Clin Neurophysiol. 2003;114:1379–89.

    Article  Google Scholar 

  14. Dietz V, Colombo G, Jensen L, et al. Locomotor capacity of spinal cord in paraplegic patients. Ann Neurol. 1995;37:574–82.

    Article  Google Scholar 

  15. Dietz V, Colombo G. Effects of body immersion on postural adjustments to voluntary arm movements in humans: role of load receptor input. J Physiol. 1996;497:849–56.

    Article  Google Scholar 

  16. Dietz V, Wirz M, Curt A, et al. Locomotor pattern in paraplegic patients: training effects and recovery of spinal cord function. Spinal Cord. 1998;36:380–90.

    Article  Google Scholar 

  17. Dietz V. Do human bipeds use quadrupedal coordination? Trends Neurosci. 2002;25:462–7.

    Article  Google Scholar 

  18. Dietz V. Neuronal plasticity after a human spinal cord injury: positive and negative effects. Exp Neurol. 2012;235:110–5.

    Article  Google Scholar 

  19. Ditunno JF, Graziani V, Tessler A. Neurological assessment in spinal cord injury. Adv Neurol. 1997;72:325–33.

    Google Scholar 

  20. Ditunno JF Jr, Barbeau H, Dobkin BH, et al. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair. 2007;21:539–50.

    Article  Google Scholar 

  21. Dobkin B, Apple D, Barbeau H, et al. Weight-supported treadmill vs. over-ground training for walking after acute incomplete SCI. Neurology. 2006;66:484–93.

    Article  Google Scholar 

  22. Dobkin B, Harkema S, Requejo P, et al. Modulation of locomotor-like EMG activity in subjects with complete and incomplete spinal cord injury. J Neurol Rehabil. 1995;9:183–90.

    Google Scholar 

  23. Esquenazi A, Talaty M, Packel A, Saulino M. The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury. Am J Phys Med Rehabil. 2012;91:911–21.

    Google Scholar 

  24. Farris R, Quintero H, Murray S, et al. A preliminary assessment of legged mobility provided by a lower limb exoskeleton for persons with paraplegia. IEEE Trans Neural Syst Rehabil Eng. 2014;22:482–90.

    Article  Google Scholar 

  25. Ferris DP, Czerniecki JM, Hannaford B. An ankle-foot orthosis powered by artificial pneumatic muscles. J Appl Biomech. 2005;21:189–97.

    Article  Google Scholar 

  26. Fleischer C. Controlling exoskeletons with EMG signals and a biomechanical body model. Dissertation, TU Berlin; 2007.

    Google Scholar 

  27. Fleischer C, Hommel G. Calibration of an EMG-based body model with six muscles to control a leg exoskeleton. In: Proceedings of the 2007 IEEE International Conference on Robotics and Automation (ICRA07). 2007, p. 2514–2519.

    Google Scholar 

  28. Graupe DH, Cerrel-Bazo H Kern, et al. Walking performance, medical outcomes and patient training in FES of innervated muscles for ambulation by thoracic-level complete paraplegics. Neurol Res. 2008;30:123–30.

    Article  Google Scholar 

  29. Harkema S, Dobkin BH, Edgerton VR. Pattern generators in locomotion: implications for recovery of walking after spinal cord injury. Top Spinal Cord Injury Rehabil. 2000;6:82–96.

    Article  Google Scholar 

  30. Harkema SJ, Hurley SL, Patel UK, et al. Human lumbosacral spinal cord interprets loading during stepping. J Neurophysiol. 1997;77:797–811.

    Article  Google Scholar 

  31. Hernigou P. Ambroise pare IV: the early history of artificial limbs (from robotic to prostheses). Int Orthop. 2013;37:1195–7.

    Article  Google Scholar 

  32. Hesse S, Werner C, Paul T, et al. Influence of walking speed on lower limb muscle activity and energy consumption during treadmill walking of hemiparetic patients. Arch Phys Med Rehabil. 2001;82:1547–50.

    Article  Google Scholar 

  33. Hidler J, Sainburg R. Role of robotics in neurorehabilitation. Top Spinal Cord Inj Rehabil. 2011;17:42–9.

    Article  Google Scholar 

  34. Hubli M, Dietz V. The physiological basis of neurorehabilitation–locomotor training after spinal cord injury. J Neuroeng Rehabil. 2013;10:5.

    Article  Google Scholar 

  35. Kawamoto H, Kanbe S, Sankai Y. Power assist method for HAL3 estimating operator’s intention based on motion information. In: Proceedings of the 2003 IEEE International Workshop on Robot and Human Interactive Communication. 2003, p. 67–72.

    Google Scholar 

  36. Kazerooni H. Exoskeletons for human power augmentation. Intelligent Robots and Systems, 2005 (IROS). In: Proceedings of the 2005 IEEE/RSJ International Conference. 2005;3459–64.

    Google Scholar 

  37. Kolakowsky-Hayner SA. Safety and feasibility of using the EksoTM bionic exoskeleton to aid ambulation after spinal cord injury. J Spine 2013;S4:1–8.

    Google Scholar 

  38. Lam T, Wolfe D, Eng J, Domingo A. Lower limb rehabilitation following spinal cord injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. 2010;1–47.

    Google Scholar 

  39. Liu X, Low KH. Development and preliminary study of the NTU lower extremity exoskeleton. Cybernetics and Intelligent Systems, IEEE Conference on 2004 (vol. 2, p. 1099–106).

    Google Scholar 

  40. Liu X, Low KH, Yu HY. Development of a lower extremity exoskeleton for human performance enhancement. Intelligent Robots and Systems, 2004 (IROS). Proceedings of the 2004 IEEE/RSJ International Conference on, 2004 (vol. 4, p. 3889–94).

    Google Scholar 

  41. MacKay-Lyons M. Central pattern generation of locomotion: a review of the evidence. Phys Ther. 2002;82:69–83.

    Article  Google Scholar 

  42. Maegele M, Muller S, Wernig A, et al. Recruitment of spinal motor pools during voluntary movements versus stepping after human spinal cord injury. J Neurotrauma. 2002;19:1217–29.

    Article  Google Scholar 

  43. Marchal-Crespo L, Reinkensmeyer DJ. Review of control strategies for robotic movement training after neurologic injury. J Neuroeng Rehabil. 2009;6:20.

    Article  Google Scholar 

  44. Moreno JC, Barroso F, Farina D, et al. Effects of robotic guidance on the coordination of locomotion. J NeuroEng Rehabil. 2013;10:79.

    Article  Google Scholar 

  45. Moreno JC, Del Ama AJ, de Los Reyes-Guzman A, et al. Neurorobotic and hybrid management of lower limb motor disorders: a review. Med Biol Eng Comput 2011;49:1119–1130.

    Google Scholar 

  46. Neuhaus PD, Noorden JH, Craig TJ, et al. Design and evaluation of mina: a robotic orthosis for paraplegics. IEEE Int Conf Rehabil Robot. 2011; 2011:5975468.

    Google Scholar 

  47. Nightingale EJ, Raymond J, Middleton JW, et al. Benefits of FES gait in a spinal cord injured population. Spinal Cord. 2007;45:646–57.

    Article  Google Scholar 

  48. Pearson KG. Role of sensory feedback in the control of stance duration in walking cats. Brain Res Rev. 2008;57:222–7.

    Article  Google Scholar 

  49. Pons JL. Wearable Robots. Chicester, UK: Wiley; 2008.

    Book  Google Scholar 

  50. Rainetau O, Schwab ME. Plasticity of motor systems after incomplete spinal cord injury. Nat Rev Neurosci. 2001;2:263–73.

    Article  Google Scholar 

  51. Sanz-Merodio D, Cestari M, ArevaloJ C, et al. A lower-limb exoskeleton for gait assistance in quadriplegia. EEE international conference on robotics and biomimetics: ROBIO. 2012;2012:107511–4.

    Google Scholar 

  52. Sawicki GS, Gordon KE, Ferris DP. Powered lower limb orthoses: applications in motor adaptation and rehabilitation. In: Rehabilitation Robotics, 2005 (ICORR). 9th International Conference on 2005, p. 206–11.

    Google Scholar 

  53. Simpson LA, Eng JJ, Hsieh JTC, et al. The Health and life priorities of individuals with spinal cord injury: a systematic review. J Neurotrauma. 2012;29:1548–55.

    Article  Google Scholar 

  54. Stein J, Bishop L, Stein DJ, et al. Gait training with a robotic leg brace after stroke: a randomized controlled pilot study. Am J Phys Med Rehabil. 2014;93:987–94.

    Article  Google Scholar 

  55. Strausser KA, Kazerooni H. The development and testing of a human machine interface for a mobile medical exoskeleton. In: IEEE/RSJ International Conference on Intelligent Robots and Systems (IROS), 2011. Piscataway, NJ: IEEE.

    Google Scholar 

  56. Strausser KA, Swift TA, Zoss AB et al. Prototype medical exoskeleton for paraplegic mobility: first experimental results. In: ASME 2010 dynamic systems and control conference: DSCC, 2010.

    Google Scholar 

  57. Sylos-Labini F, La Scaleia V, d’Avella A, et al. EMG patterns during assisted walking in the exoskeleton. Front Human Neurosci. 2014;8:423.

    Article  Google Scholar 

  58. Thrasher TA, Popovic MR. Functional electrical stimulation of walking: function, exercise and rehabilitation. Ann Readapt Med Phys. 2008;51:452–60.

    Article  Google Scholar 

  59. Van Hedel H, Dietz V. Rehabilitation of locomotion after spinal cord injury. Restor Neurol Neurosci. 2010;28:123–34.

    Google Scholar 

  60. Wernig A, Muller S, Nanassy A, et al. Laufband therapy based on “rules of spinal locomotion” is effective in spinal cord injured persons. Eur J Neurosci. 1995;7:823–9.

    Article  Google Scholar 

  61. Yamamoto K, Ishii M, Noborisaka H et al. Stand alone wearable power assisting suit-sensing and control systems. Robot and Human Interactive Communication, 2004. ROMAN 2004. 13th IEEE International Workshop on 2004, p. 661–6.

    Google Scholar 

  62. Yang JF, Musselman KE. Training to achieve over ground walking after spinal cord injury: a review of who, what, when, and how. J Spinal Cord Med. 2012;35:293–304.

    Article  Google Scholar 

  63. Zeilig G, Weingarden H, Zwecker M, et al. Safety and tolerance of the ReWalk exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study. J Spin Cord Med. 2012;35:96–101.

    Article  Google Scholar 

  64. Zoss A, Kazerooni H, Chu A. On the mechanical design of the Berkeley Lower Extremity Exoskeleton (BLEEX). Intelligent Robots and Systems, 2005 (IROS). Proceedings of the 2005 IEEE/RSJ International Conference on 2005, p. 3465–72.

    Google Scholar 

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Authors and Affiliations

  1. Neuro-Robot Rehabilitation Lab, Fondazione Santa Lucia IRCCS, Rome, Italy

    Marco Molinari, Federica Tamburella, Nevio Luigi Tagliamonte & Iolanda Pisotta

  2. Spinal Rehabilitation Lab, Fondazione Santa Lucia IRCCS, Rome, Italy

    Marcella Masciullo, Federica Tamburella & Nevio Luigi Tagliamonte

  3. Neural Rehabilitation Group, Cajal Institute, Spanish National Research Council (CSIC), Madrid, Spain

    José L. Pons

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  1. Marco Molinari
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  2. Marcella Masciullo
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  3. Federica Tamburella
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  4. Nevio Luigi Tagliamonte
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  5. Iolanda Pisotta
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  6. José L. Pons
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Correspondence to Marco Molinari .

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Editors and Affiliations

  1. Department of Brain and Behavioural Sciences, University of Pavia, C. Mondino National Neurological Institute, Pavia, Italy

    Giorgio Sandrini

  2. SRH Gesundheitszentrum Bad Wimpfen , Bad Wimpfen, Germany

    Volker Homberg

  3. Department of Neurology, Hospital Hochzirl, Zirl, Austria

    Leopold Saltuari

  4. Department of Neurological, Biomedical and Movement Sciences, Verona University, Verona, Italy

    Nicola Smania

  5. Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy

    Alessandra Pedrocchi

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Molinari, M., Masciullo, M., Tamburella, F., Tagliamonte, N.L., Pisotta, I., Pons, J.L. (2018). Exoskeletons for Over-Ground Gait Training in Spinal Cord Injury. In: Sandrini, G., Homberg, V., Saltuari, L., Smania, N., Pedrocchi, A. (eds) Advanced Technologies for the Rehabilitation of Gait and Balance Disorders. Biosystems & Biorobotics, vol 19. Springer, Cham. https://doi.org/10.1007/978-3-319-72736-3_18

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  • DOI: https://doi.org/10.1007/978-3-319-72736-3_18

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